Form Cms-671 - Ltc Facility Application For Medicare/medicaid Page 2

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FACILITY STAFFING
A
B
C
D
Services
Full-Time Staff
Tag
Part-Time Staff
Contract
Provided
(hours)
Number
(hours)
(hours)
1
2
3
Administration
F33
F34
Physician Services
F35
Medical Director
F36
Other Physician
F37
Physician Extender
F38
Nursing Services
F39
RN Director of Nurses
Nurses with Admin. Duties
F40
Registered Nurses
F41
Licensed Practical/
F42
Licensed Vocational Nurses
Certified Nurse Aides
F43
F44
Nurse Aides in Training
Medication Aides/Technicians
F45
Pharmacists
F46
Dietary Services
F47
Dietitian
F48
Food Service Workers
F49
Therapeutic Services
F50
Occupational Therapists
F51
Occupational Therapy Assistants
F52
F53
Occupational Therapy Aides
F54
Physical Therapists
Physical Therapists Assistants
F55
Physical Therapy Aides
F56
F57
Speech/Language Pathologist
F58
Therapeutic Recreation Specialist
F59
Qualified Activities Professional
Other Activities Staff
F60
Qualified Social Workers
F61
Other Social Services
F62
Dentists
F63
Podiatrists
F64
Mental Health Services
F65
Vocational Services
F66
F67
Clinical Laboratory Services
F68
Diagnostic X-ray Services
Administration & Storage of Blood
F69
Housekeeping Services
F70
Other
F71
Name of Person Completing Form
Time
Signature
Date
Form CMS-671 (12/02)

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